§4319. Rebates

1.Rebates required.
Carriers must provide rebates in the large group, small group and individual markets
to the extent required by the federal Affordable Care Act and federal regulations
adopted pursuant thereto if the medical loss ratio under subsection 2 is less than
the minimum medical loss ratio under subsection 3.

[
2011, c. 90, Pt. D, §5 (NEW)
.]

2.Medical loss ratio.
For purposes of this section, the medical loss ratio is the ratio of the numerator
to the denominator as described in paragraphs A and B, respectively, plus any credibility
adjustment. The period for which the medical loss ratio is determined and the meaning
of all terms used in this subsection must be in accordance with the federal Affordable
Care Act and federal regulations adopted pursuant thereto. For the purposes of this
subsection:

A. The numerator is the amount expended on reimbursement for clinical services provided
to enrollees and activities that improve health care quality; and [2011, c. 90, Pt. D, §5 (NEW).]

B. The denominator is the total amount of premium revenue excluding federal and state
taxes and licensing and regulatory fees paid and after accounting for payments or
receipts for risk adjustment, risk corridors and reinsurance pursuant to federal law. [2011, c. 90, Pt. D, §5 (NEW).]

[
2011, c. 90, Pt. D, §5 (NEW)
.]

3.Minimum medical loss ratio.
The minimum medical loss ratio is:

A. In the large group market, 85%; [2011, c. 90, Pt. D, §5 (NEW).]

B. In the small group market, 80%; and [2011, c. 90, Pt. D, §5 (NEW).]

C. In the individual market, 80% or such lower minimum medical loss ratio as the Secretary
of the United States Department of Health and Human Services determines based on a
finding, pursuant to the federal Affordable Care Act and federal regulations adopted
pursuant thereto, that an 80% minimum medical loss ratio might destabilize the individual
market in this State. [2011, c. 90, Pt. D, §5 (NEW).]

[
2011, c. 90, Pt. D, §5 (NEW)
.]

SECTION HISTORY

2011, c. 90, Pt. D, §5 (NEW).

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